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General NPI Number Information
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NPI Number | 1437066826
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Entity Type | Organization
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Legal Business Name | OAK TREE SUPPORTED LIVING
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Dates
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Enumeration Date | 08/24/2026
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Last Update Date | 08/24/2026
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Provider Practice Location Address
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Address Line | 522 W RIVERSIDE AVE
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City | SPOKANE
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State | WA
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Zip | 99201-0580
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Country | US
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Telephone | 208-620-1477
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Fax |
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Provider Business Mailing Address
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Address Line | 1390 E ELDERBERRY CIR
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City | COEUR D ALENE
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State | ID
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Zip | 83815-6559
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Country | US
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Telephone | 208-620-1477
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Fax |
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | HEIDI PROVENCE
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Credential |
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Telephone | 208-620-1477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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